Association among income loss, financial strain and depressive symptoms during COVID-19: evidence from two longitudinal studies.

BACKGROUND: The COVID-19 pandemic has major ramifications for global health and the economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between COVID-19 pandemic-related income loss with financial strain and mental health trajectories over a 1-month course. METHODS: Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; N = 4 171) and at a 1-month follow-up (T2; N = 1 559). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. FINDINGS: In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). INTERPRETATION: Income loss and financial strain were uniquely associated with depressive symptoms and the exacerbation of symptoms over time, above and beyond pandemic-related anxiety. Considering the painful dilemma of lockdown versus reopening, with the tradeoff between public health and economic wellbeing, our findings provide evidence that the economic impact of COVID-19 has negative implications for mental health. FUNDING: This study was supported by grants from the National Institute of Mental Health, the US-Israel Binational Science Foundation, Foundation Dora and Kirsh Foundation.

Mental illness and intellectual disability in Magistrates Courts in New South Wales, Australia.

BACKGROUND: Little is known about the prevalence of intellectual disability (ID) and/or cognitive impairment (CI) among accused persons in the Magistrates (Local) Courts, the personal, health and mental health characteristics of this cohort, and their service provision needs in the community. The study aimed to determine the prevalence of dual diagnoses of ID and/or CI and psychiatric disorder in a sample of accused persons appearing before four Magistrates Courts. Accused persons with ID and/or CI may not be identified in the Magistrates Court as having a disability and therefore may be unable to access the legal safeguards which exist for their protection within the criminal justice system and/or may fail to receive appropriate community health and welfare services. METHOD: The sample was drawn from accused persons aged over 18 years appearing before four Magistrates Courts in metropolitan and urban areas of a large city. Participants were assessed using the Kaufman Brief Intelligence Test, Second Edition (KBIT-2), Vineland Adaptive Behavior Scales, Second Edition (VABS2) and the Psychiatric Assessment Schedules for Adults with Developmental Disabilities Checklist. RESULTS: On the KBIT-2, 10% of participants achieved a standard score (SS) below 70 (mild ID range) and a further 20% were in the 70-79 (borderline) range. The VABS2 results indicated that 12% of participants had SS below 70 and a further 9% were in the 70-79 (borderline) range. The prevalence of mental illness in the group with intellectual deficits was 46%, compared with a prevalence of 36% for those without intellectual deficits. CONCLUSIONS: People with ID and/or CI were found to be over-represented in the Magistrates Court. Furthermore, results highlight the unmet mental health needs of this cohort in the criminal justice system. The results of the study have implications for the planning of services and diversionary options to facilitate better management of defendants with ID and/or CI with mental health needs.

Psychotic manifestations of alcoholism.

The psychotic manifestations of alcohol physical and psychiatric disorders have been documented for many centuries; however, the distinction of the various disorders remains less well defined. Individuals often have comorbid elements of several disorders, and the psychotic phenomenon are often diverse. The psychotic manifestations of alcohol withdrawal, delirium tremens, alcohol hallucinosis, Wernicke's-Korsakoff's psychosis, alcohol pellagra and hepatic encephalopathy, Marchiafava-Bignami, central pontine myelinosis, and alcohol dementia are discussed in this article.

Differentiation of homicidal child molesters, nonhomicidal child molesters, and nonoffenders by phallometry.

OBJECTIVE: The purpose of this study was to examine the ability of phallometry to discriminate among homicidal child molesters, nonhomicidal child molesters, and a comparison group of nonoffenders. METHOD: Twenty-seven child molesters who had committed or had attempted a sexually motivated homicide, 189 nonhomicidal child molesters, and 47 nonoffenders were compared on demographic variables and psychometrically determined responses to aural descriptions of sexual vignettes. Two phallometric indexes were used: the pedophile index and the pedophile assault index. The pedophile index was computed by dividing the subject's highest response to an aural description of sex with a "consenting" child by his highest response to description of sex with a consenting adult. The pedophile assault index was computed by dividing the subject's highest response to an aural description of assault involving a child victim by his highest response to description of sex with a "consenting" child. RESULTS: Homicidal child molesters, nonhomicidal child molesters, and nonoffenders were not significantly different in age or IQ. Homicidal and nonhomicidal child molesters had significantly higher pedophile index scores than nonoffenders. Significantly more homicidal child molesters (14 [52%] of 27) and nonhomicidal child molesters (82 [46%] of 180) than nonoffenders (13 [28%] of 47) had pedophile index scores equal to or greater than 1.0, but homicidal and nonhomicidal child molesters did not differ from each other. Significantly more homicidal child molesters (17 [63%] of 27) than either nonhomicidal child molesters (71 [40%] of 178) or nonoffenders (17 [36%] of 47) had pedophile assault index scores equal to or greater than 1.0, and nonhomicidal child molesters and nonoffenders were not significantly different from each other. Within-group analyses revealed that of the three groups, only the nonhomicidal child molesters exhibited a significant difference between their pedophile index scores and their pedophile assault index scores; their pedophile index scores were higher. CONCLUSIONS: Consistent with past research, the authors found that the pedophile index is useful in differentiating homicidal and nonhomicidal child molesters from nonoffenders and that the pedophile assault index is able to differentiate homicidal child molesters from nonhomicidal child molesters and nonoffenders.

The relationship of deviant sexual arousal and psychopathy in incest offenders, extrafamilial child molesters, and rapists.

The relationship between deviant sexual arousal, as measured by auditory phallometric stimuli, and psychopathy, as measured by the Psychopathy Checklist-Revised, was examined in 156 incest offenders, 260 extrafamilial child molesters, and 123 rapists. Subjects in each group had never been convicted of another type of sexual offense. Replicating previous research, rapists were more psychopathic than incest offenders and child molesters. Deviant sexual arousal to auditory stimuli was evident only on the Pedophile Index for child molesters. When the relationship between psychopathy and deviant sexual arousal was evaluated in the three groups combined, several significant correlations emerged. However, a finer analysis of these correlations revealed that child molesters evidenced a significant correlation between psychopathy and the Rape Index and psychopathy and the Pedophile Index. There were no such significant findings in the incest offender or rapist groups. Implications of the results are discussed.

Prediction of recidivism in extrafamilial child molesters based on court-related assessments.

One hundred ninety-two convicted extrafamilial child molesters were followed for an average of 7.8 years after their conviction. The percentage of men who had committed a sexual, a violent, or any criminal offense by the 12th year was 15.1, 20.3, and 41.6, respectively. The sexual recidivists, compared with the nonrecidivists; demonstrated more problems with alcohol and showed greater sexual arousal to assaultive stimuli involving children than to mutually consenting stimuli with children. The violent recidivists, compared with the nonrecidivists, were more likely to have a history of violence in the families in which they were raised and were rated significantly more psychopathic on the Psychopathy Checklist--Revised (PCL-R). They also showed more sexual arousal to stimuli depicting mutually consenting sexual interactions with children than to adult stimuli. In terms of any criminal recidivism, recidivists were younger, had completed fewer years of school, and were raised in psychologically more harmful family environments compared with nonrecidivists. They also reported that, before 16 years of age, they were more likely to have been physically abused and were more likely to have been removed from their homes compared to those that did not recidivate. In addition, recidivists demonstrated more general hostility on the Buss-Durkee Hostility Inventory and were rated significantly more psychopathic on the PCL-R. The phallometric assessments revealed, that the criminal recidivists, compared to the nonrecidivists, showed more sexual arousal to stimuli depicting coercive sexual activity with children than consenting sexual activities with children. In addition, they showed more sexual arousal to scenes depicting adult rape then adult mutually consenting sex. Finally, the recidivists also had more charges or convictions for violence and any criminal acts. The small number of significant differences between recidivists and nonrecidivists in the sexual and violent categories precluded an attempt to determine which combination of factors meaningfully predicted reoffending. However, for criminal recidivism, a stepwise discriminant function analysis to assess the combination of factors that most successfully distinguished between groups in terms of criminal recidivism was significant, with subjects' age, total number of criminal convictions, and pedophile assault index being retained for optimal prediction. The procedure correctly classified 70.6% of the original group, 82.8% of the nonrecidivists, and 52.6% of the recidivists. PCL-R Total Score alone was equally successful in a similar discriminant function.

Sexual recidivism in sex offenders.

OBJECTIVE: To examine the recidivism rates of the various types of adult sex offenders including incest offenders, extrafamilial child molesters, exhibitionists, and rapists. METHOD: An examination of the literature over the past 4 decades and the data from our own study group. RESULTS: Methodological shortfalls and differences across the studies make statistical appraisal of the results difficult. Nevertheless, there is a consensus that incest offenders are less likely to reoffend compared with extrafamilial child molesters. Rapists and exhibitionists are thought to be at a higher risk for recidivism. CONCLUSION: A combined actuarial predictive approach in conjunction with empirically guided clinical assessment is probably the best method to predict recidivism of sex offenders.

Recidivism in convicted rapists.

Factors associated with recidivism in 86 men convicted of rape were studied. These men had been out of prison for up to 12 years (mean, 7.6 years). The majority of the men had been assessed in a sexual behaviors clinic of a general psychiatric hospital at the time of their conviction. Almost 50 percent of the group had committed some offense by the fifth year out of prison. The recidivism rates for sexual, violent, and any criminal recidivism were 16 percent, 26 percent, and 53 percent, respectively. The ability to predict sexual and violent recidivism in this population of rapists was rather poor. More sexual recidivists, compared with nonrecidivists, had been removed from their family home prior to age 16. Violent recidivists compared with nonrecidivists were also more frequently removed from their homes prior to 16 years of age, and they showed significantly more problems with alcohol. In terms of any criminal recidivism, recidivists compared with nonrecidivists were younger and scored higher on the Michigan Alcohol Screening Test (MAST). They also had more previous charges and/or convictions for violent offenses and more charges and/or convictions for any criminal acts. The combination of age and MAST scores was able to predict 92.6 percent of the nonrecidivists and 53.3 percent of the recidivists. The outstanding feature of the total group of rapists was their poor sexual adjustment as indicated on the Derogatis Sexual Functioning Inventory, on which they scored at approximately the seventh percentile of the population at large. There was also an indication that rapists have problems with hostility, as measured by the Buss-Durkee Hostility Inventory. Furthermore, the range of scores on the MAST indicated that the total group of rapists has serious problems with alcohol. The inability of phallometric assessments and psychopathy as measured by the Psychopathy Checklist-R to predict recidivism are discussed.

Homicidal sex offenders: psychological, phallometric, and diagnostic features.

Homicidal sex offenders represent an understudied population in the forensic literature. Forty-eight homicidal sex offenders assessed between 1982 and 1992 were studied in relation to a comparison group of incest offenders. Historical features, commonly used psychological inventories, criminal histories, phallometric assessments, and DSM diagnoses were collected on each group. The homicidal sex offenders, compared with the incest offenders, self-reported that they had more frequently been removed from their homes during childhood and had more violence and forensic psychiatric contact in their histories. On the self-report psychological inventories, the homicidal sex offenders portrayed themselves as functioning significantly better in the areas of sexuality (Derogatis Sexual Functioning Inventory) and aggression/hostility (Buss-Durkee Hostility Inventory). However, on the Psychopathy Checklist-Revised (PCL-R), researchers rated the homiciders significantly more psychopathic than the incest offenders on Factor 1 (personality traits) and Factor 2 (antisocial history). Police records revealed the homicidal subjects also had been charged or convicted of more violent and nonviolent nonsexual offenses. The phallometric assessments indicated that the homicidal sex offenders demonstrated higher levels of response to pedophilic stimuli and were significantly more aroused to stimuli depicting assaultive acts to children, relative to the incest offenders. Despite the homiciders' self-reports of fairly good psychological functioning, DSM-III diagnoses reliably discriminated between the groups. A large number of homicidal sex offenders were diagnosed as suffering from psychosis, antisocial personality disorder, paraphilias, sexual sadism, sexual sadism with pedophilia, and substance abuse. Seventy-five percent of the homicidal sex offenders had three or more diagnoses compared with six percent of the incest offenders. The article addresses the role of "hard" versus "soft" measures in the assessment and treatment of violent sex offenders. In addition, the usefulness of phallometric assessments and the PCL-R and its subscales are considered.

Co-morbidity of alcoholism and the paraphilias.

Alcoholism has been related to a wide variety of crimes. Various authors have studied the prevalence of alcoholism in relationship to incest, rape and pedophilia. This study evaluates the co-morbidity of alcoholism and the specific paraphilias including sexual sadism, fetishism, incest, pedophilia, exhibitionism and transvestism. Rapists were included although by definition it is not strictly a paraphilic disorder. Seven hundred and twenty eight paraphilic individuals were evaluated. More than 50% of sexual sadists were alcoholics. Alcoholism in association with sexual sadists was statistically significant as compared to transvestites, rapists, pedophiles, and incest offenders. Transvestism had the lowest relative rate of alcoholism. The authors discuss these findings and the role alcoholism plays in causing violent sexual behavior in individuals with paraphilias.

Are pedophiles with aggressive tendencies more sexually violent?

Pedophiles use varying degrees of persuasion, coercion, and physical force in their sexual assaults. Pedophiles may also display aggressiveness and characteristics of hostility in nonsexual areas of their behavior. This study (N = 263) investigates the relationship between pedophiles with aggressive tendencies and the degree of sexual violence in their pedophilic acts. The degree of sexual violence was rated subjectively after a comprehensive psychiatric and psycho-sexual assessment and obtaining collateral information from police reports and witness statements. The degree of sexual violence was also rated more objectively using the penile plethysmography. Strict DSM-IV pedophilic disorder criteria were adopted for this study. The authors discuss whether sexual violence in a pedophilic population is focused to sexual areas or tends to be more generalized in other physically aggressive and hostile areas.

A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study.

Treatment of the paraphilic disorders using behavioral, cognitive, pharmacological, and social interventions has been shown to have limited success with poorly motivated or noncompliant patients. Researchers have speculated on the role of the serotonergic system in the paraphilic disorders. Recent anecdotal studies have reported successful results with the selective serotonin reuptake inhibitors (SSRIs) in the treatment of the paraphilic disorders. This retrospective study evaluates and compares the effectiveness of three SSRIs in a group of paraphilics (N = 58). The individual effectiveness of fluvoxamine, fluoxetine, and sertraline were examined and compared. Results found that the severity of fantasies decreased and that there were no significant differences in the reported efficacy between fluvoxamine, fluoxetine, and sertraline. Although double blind placebo crossover studies are still needed to assess the efficacy of these agents, this study further supports the growing body of literature on the potential use of these drugs in the treatment of the paraphilias.

Infantophilia--a new subcategory of pedophilia?: a preliminary study.

The Diagnostic and Statistical Manual of Mental Disorders has included three subgroups of pedophilic disorder based on the gender of the victim, the exclusiveness of the subject's preference for children, and whether the behavior is limited to incest. This study uses the pedophile's preference for age of victim as a means of delineating two distinct subgroups. The first group of so-called 'infantophiles' had victims who were less than five years old, while the latter subgroup of pedophiles had victims between the ages of 6 and 12 years (n = 38). The primary purpose of this study is to test the hypothesis that these two subgroups, based on the age of the victims, can be further distinguished by descriptive parameters. Various standardized questionnaires were administered to the subjects. The results of the study are discussed and suggestions made with regard to future research efforts.

Capacity to stand trial: pitfalls of legal interpretation.

Legally, the concept of fitness to stand trial is fixed and absolute. Psychiatrists view fitness as a homeostatic functional capacity. The Ontario Court of Appeal recently set a precedent (Queen versus Taylor) for a standard of fitness to stand trial by interpreting the criteria for unfitness as defined in terms of Section 2 of the Criminal Code. They held that only a factual understanding of these criteria is required by the courts. A person suffering from acute psychotic symptoms with delusions which relate to the subject matter of the trial, who act contrary to their best interests and who are disruptive in their behaviour to the orderly flow of the trial may still fulfill the criteria for fitness to stand trial. The writer illustrates some important implications of this decision and suggests recommendations to current legal interpretations of a clinical capacity.

Family practice residents' decision making regarding future practice of obstetrics.

BACKGROUND: This study assesses the attitudes of family practice residents toward their future practice of obstetrics. The decline of family practice obstetrics has resulted in problems of access to care for many areas. METHODS: Questionnaires were sent to 30 family practice residency programs and were distributed to 353 2nd- and 3rd-year residents; the overall response rate was 85 percent. Respondents were asked to describe factors contributing to their decision whether to practice obstetrics. RESULTS: Seventy-two percent of the respondents indicated plans for future obstetrics practice. Reasons for choosing to practice obstetrics included personal interest, believing that obstetrics is an important part of family health care, and desire for diversity in practice. Primary concerns included interference with personal life, fear of lawsuits, and insurance premiums. Those deciding not to practice obstetrics cited interference with personal or professional life and desire for limited practice as deterrents. Important demographic variables predicting future practice included female sex, geographic location, and type of practice desired. CONCLUSION: This study portrays a resurgence in the percentage of family practice residents planning to practice obstetrics and discusses aspects of the training system that merit support to increase the number of family physicians providing obstetric care.

Using drugs to facilitate sexual behavior is associated with sexual variety among injection drug users.

Little normative data exist about the frequency and variety of sexual behavior of injection drug users. Sexual behaviors of a group of 313 injection drug users (225 men and 88 women) were assessed by a structured interview at the start of an acquired immune deficiency syndrome prevention project. Celibacy was reported by 12.3% of men and 26.9% of women in the year before the initial interview. Male injection drug users who had been sexually active reported a mean number of 4.61 (median, 2.0) female sexual partners in the previous year; sexually active women reported a mean number of 5.28 (median, 1.0) male sexual partners. Sexually active men and women reported median condom use frequency at 0% of vaginal intercourse events (mean for men, 10.31%; mean for women, 14.48%). Male injection drug users who reported using drugs to help them relax for sex, to enhance sexual performance, or to meet sexual partners reported greater frequency of anal intercourse, fellatio, and cunnilingus, less relative frequency of vaginal intercourse, more sexual partners, and greater involvement in being paid for sex and paying for sex than did men who did not report using drugs to enhance sex. Men who used drugs to enhance sex also reported higher frequency of use of a number of different drug classes than men who did not use drugs to enhance sex. For women, using drugs to enhance sex was related to greater frequency of anal intercourse and having more sexual partners. Implications for treatment of drug abusers and future research are discussed.

A comparison of sexual victimization in the childhoods of pedophiles and hebephiles.

The association between perpetration of sexual abuse and the offender's own victimization as a child has been well documented in the literature. Various researchers have examined this relationship by assessing the exclusiveness of the sexual abuser's behavior, the gender of his victims and the gender of his own childhood abuser. This study was designed to assess the differences between pedophiles and hebephiles in features of their own childhood victimization. Subjects were 135 pedophiles and 43 hebephiles who admitted to their offences. A total of 42% of pedophiles and 44% of hebephiles reported being sexually victimized in their own childhoods. Pedophiles reported being molested at a younger age than hebephiles. Both groups appear to chose their age specific victims in accordance with the age of their own experience of sexual victimization. Although the cause of child molestation remains undetermined these results support social learning and modeling theories.

Longitudinal sexual behavior changes in injecting drug users.

OBJECTIVE: To determine whether injection drug users (IDU) maintained sexual behavior risk reduction over an 18-month period that had been noted previously over a 4-month period. DESIGN: A repeated measures design was utilized with IDU assessed initially at study enrollment and again 18 months later. METHODS: Sexual behaviors of a group of 220 IDU (148 men and 72 women) were assessed by a structured interview at the start of an AIDS prevention project and again 18 months later. RESULTS: Having multiple sex partners during the 12 months before initial assessment was reported by 42.6% of the men and 35.7% of the women. Significantly fewer had multiple sex partners during the 10 months before follow-up assessment (men, 20.9%; women, 14.3%). Condom use for vaginal intercourse increased from a mean of 11.9% initially to 27.8% at follow-up for men. The increase in condom use was greater for those with multiple sex partners. Women did not report significant increases in condom use. Continued involvement in unsafe sexual behaviors was associated with exchanging sex for money or drugs, using drugs to help meet sexual needs, alcohol use and drug use. CONCLUSIONS: Risk reductions noted previously were maintained over 18 months for the majority of the sample. Drug-use treatment and interventions that closely examine the interplay between drug use and sexuality for individual IDU are recommended as strategies to further reduce the sexual risk of HIV transmission among IDU.

Substance abuse and criminal behavior.

As forensic psychiatry develops as a clinical subspecialty, clinical skill in understanding, treating, and predicting violent behavior will become more important. This article addresses the importance of understanding the relationship between substance abuse and violent behavior. This article also discusses morbidity and mortality in substance abuse, the demographics of substance abuse and criminality, and the clinical aspects of the forensic psychiatric evaluation.